Permanent epicardial pacing : a first line strategy in children

Abstract

Abstract Background Permanent cardiac pacing in paediatric patients remains a challenge. According to the European Paediatric and Congenital Society (AEPC) recommendations, below 20 kg epicardial implantation is preferred, while above 20 kg endocardial implantation is given priority unless specific contraindication. In the literature, a weight at 15 kg is also found to be the minimal weight above which an endovascular implantation is considered. However, endovascular systems have been reported to be associated with a high risk of complications. Recent improvements in epicardial leads technology have significantly improved pacing thresholds (1-3), battery life and reduced the risk of re-intervention for epicardial lead dysfunction (4,5). Purpose The aim of the study is to evaluate the long-term results and efficacy of epicardial pacing in children and to investigate risk factors for epicardial lead dysfunction. Method We performed a retrospective, single-centre analysis of consecutive patients aged ˂18 years implanted with an epicardial PM between 2004 and 2020. The data collection included initial pacing parameters, at 1 month, 1 year, 2 years, and at last follow-up, as well as occurrence of early and late complications. Results A total of 101 patients (93 atrial and 131 ventricular epicardial) were analysed. The mean follow-up time was 6.2 years (range 2 days to 16.9 years). Median age at implantation was 4.2 years (IQ 0.3-8.8 years), median weight was 15.2 kg (IQ 5.2-28.0 kg). Congenital heart disease (CHD) was recorded in 59,4% of patients. Reasons for implantation were postoperative complete atrioventricular block (AVB) (40.6%), congenital AVB (37.6%), sinus dysfunction (7.9%), complete AVB with heart disease without surgery (7.9%), others (4%). Four patients had a system infection resulting in device extraction and reimplantation. The mortality rate was 15.8%, but no deaths was directly related to PM implantation or dysfunction. Detection values, impedances were stable over time, and the and average pacing thresholds remained ˂0,98±0,81 volt in the atrium and ˂ 1.57±0,89 volt in the ventricle. Lead survival was 96,7%, 90,7%, 82,3%, 74,5% at 1, 5, 8 and 10 years. The presence of CHD, weight ˂15kg, dual chamber implantation, implantation for postoperative BAV were not significant risk factors for lead dysfunction. In the group of patients implanted above 15kg the presence of a CHD significantly increased the risk of lead dysfunction (p=0.037) and all-cause reimplantation (p=0.010). In the group implanted above 15kg without any cardiopathy, the survival rate without lead dysfunction at 5 and 10 years was 100% and 90.9% respectively. Conclusion Epicardial pacing in children with steroid-eluting leads shows good long-term results with stable pacing parameters and good survival from lead dysfunction. For children implanted at a weight above 15 kg and without cardiopathy results with epicardial stimulation were excellent.Epicardial lead survival